A nurse intervention program may be used to improve the health care services provided to an injured worker. Consider, for example, a worker who submits a workers compensation claim as a result of an injury he or she received while at work. In such a situation, an insurer might arrange for a nurse to visit and provide additional health care to the worker while he or she recovers at home. Note that the improved care could result in the worker returning to his or job sooner (as compared to a worker with a similar injury who did not receive additional health care). As a result, the insurer can also benefit from providing improved health care (e.g., because the worker returned to work sooner and thus a total amount of benefits paid by the insurer might be reduced). Determining when it is appropriate to utilize a nurse intervention program, however, can be a difficult and time consuming task. For example, the decision might depend on a nature of the injury as well as details about the particular claimant. Moreover, an insurer might handle claims associated with many different accounts, and each account might have different rules and benefits that need to be considered when determining whether or not a nurse intervention program is appropriate for a particular claim.
Although some systems have attempted to apply simple rules to help determine whether or not a nurse intervention program is appropriate for a particular claim, such approaches may not effectively identify which patients and/or injuries may benefit most from these services.
The present inventors have recognized the utility of a predictive model for determining that certain insurance claims should be identified and referred for a nurse intervention program. Moreover, the use of the predictive model can be significantly enhanced by expanding the types of information used to train the predictive model and included in current claim transaction data to which the predictive model is applied, as well as by considering account-specific information associated with a particular insurance claim.